Workplace violence against healthcare workers during the COVID‐19 pandemic in Sudan: A cross‐sectional study

Abstract Background Workplace violence (WPV) against healthcare workers (HCWs) is a growing global issue. During the coronavirus diseases‐2019 (COVID‐19) pandemic, violent attacks on HCWs have been documented worldwide. This study aimed to investigate the magnitude and pattern of WPV among HCWs in Sudan during the COVID‐19 pandemic. Methods A web‐based cross‐sectional study of WPV was conducted among registered medical and health workers (pharmacists, physicians, dentists, nurses, laboratory technicians, and administrative and paramedical staff) during the COVID‐19 pandemic in Sudan. Data were collected from August to December 2021 using a self‐administered questionnaire distributed through social media platforms. Results A total of 792 HCWs returned the online questionnaire. The mean age was 33.5 ± 8.6 years, where more than half were females (54.9%) and working during the day shift (58.8%). During the COVID‐19 pandemic, three out of every four participants (78.3%) reported experiencing violence, with 65.8 % experiencing it more than three times. The common types of violence experienced were verbal (91.6%), physical (50.0%), and sexual abuse (11.0%). The emergency department reported the highest number of violent incidents (46.9%). Half of these violent events were not reported (50.3%), primarily due to a lack of a reporting system. The demographic factors that were significantly associated with exposure to violence were participants’ occupation (p < 0.001), age (p = 0.001), marital status (p = 0.002), and years of working experience (p = 0.020). Conclusion WPV was rampant among the HCWs in Sudan during the COVID‐19 pandemic. The current findings are presented to draw the attention of policy leaders and stakeholders in Sudan to this alarming problem prompting the pressing need for policy and system interventions.


INTRODUCTION
Workplace violence (WPV) against healthcare workers (HCWs) is a growing global issue in developing and developed countries. In low and middle-income countries (LMICs), violent attacks are rarely addressed due to the lack of effective governmental laws and policies protecting the HCWs [1]. The National Institute for Occupational Safety and Health defines WPV as "any violent action, including physical assaults or threats of assaults, which is directed toward persons at work or on duty" [2,3]. These violent actions can be physical, verbal, or sexual, with verbal assaults being the most common type encountered [4]. In rare cases, violence can take the form of grievous harm. It can happen in any department in the hospital and at any time with no regard or respect by the perpetrator to the place and the sick patients around [2]. WPV can occur for various reasons, including communication breakdown, unreasonable expectations, and perceived substandard care. Other reported reasons include the perceived long waiting time and the failure to meet patient and family expectations [5,6].
WPV is a serious and challenging issue in healthcare settings, especially in the situation of the coronavirus disease-2019 (COVID-19) pandemic [7,8]. The International Committee of the Red Cross (ICRC) reported 611 incidents of COVID-19related physical or verbal assaults, threats, or discrimination directed against HCWs, patients, and medical facilities in more than 40 countries during the first 6 months of the pandemic [9]. In a survey of violence in the United States in 2020, 20% of participants reported increasing on-the-job violence, which they attributed to COVID-19-related staffing shortages, changes in their patient population, and visitor restrictions [10]. During the pandemic, there has been an increase in reports of WPV attacks against HCWs in LMICs. Mistrust in HCWs, belief in conspiracy theories, limited capacity for admission of COVID-19 patients in hospitals, hospital COVID-19 policies, and blaming the HCWs for COVID-19 deaths were the most frequently cited reasons [11].
Many HCWs treating COVID-19 in Sudan have reported physical and verbal violence, damage to wards and machines, and family members forcibly entering doctors' rest lounges [12]. This has resulted in multiple strikes and demonstrations by doctors to criminalize the attacks on HCWs. A new law was approved by the transitional government in Sudan on May 25th, 2020, that stipulates "verbal or physical abuse of medical professionals, disrupting work or destroying assets in medical facilities, and publishing incorrect information that affects the performance of medical personnel can be punishable with imprisonment for up to 10 years" [13]. WPV to the HCWs has an impact on their psychological state and work performance and results in demotivation, poor job satisfaction, and early physician burnout [14][15][16]. Furthermore, it has been linked to a higher risk of suffering post-traumatic stress disorder, anxiety, and depression [17,18]. This unfortunate incident also extends to influence career choices and decisions among medical students [19].
Considerable evidence documented an increase in WPV against HCWs amidst COVID-19. For instance, a study in Iraq found that rates of violence against HCWs have increased since the pandemic began [20]. Similarly, in Jordan, there was a significant rise in violence and intimidation against HCWs and medical infrastructure [5]. Also in Egypt, a study showed a high magnitude of violence against HCWs during the pandemic [21]. Previous studies of WPV in Sudan have focused on physicians and were conducted mainly in Khartoum state [14,22]. However, there is a paucity of information regarding the extent of WPV and its associated factors among other HCWs in different parts of Sudan during the pandemic. The current study was therefore designed to investigate the extent and pattern of WPV among HCWs during the COVID-19 pandemic in Sudan.

Study design and sample population
This was a cross-sectional study reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [23]. The target population was registered medical and other health staff in Sudanese hospitals and health clinics. Pharmacists, physicians, dentists, nurses, laboratory technicians, and administrative and paramedical personnel aged 18 and above who worked in a hospital or health center during the data collection period and who had access to the internet were eligible to participate. The sample estimation was based on the total number of health workers, an alpha error of 0.05, and a margin of error of 5%, assuming a 50% predicted magnitude of WPV. The minimum required sample size was 381 participants. The calculation was done through Epi info-7 software.

Study variables, survey tool, and data collection
The dependent variable considered in this study was suffering from WPV. The question used to estimate this was "Have you encountered WPV during the COVID-19 pandemic?" with a (yes/no) answer. We did not utilize standard measurements of WPV, which are based on long/multiple questions of WPV experience, [24,25] to avoid having a lengthy questionnaire. While age, gender, employment status, marital status, years of job experience, and time-shift work (either day or night) were the F I G U R E 1 The magnitude of WPV among HCWs during the COVID-19 pandemic in Sudan, 2021 (n = 792) independent variables in this study. Other parameters assessed using closed-ended questions include frequency of WPV (once, twice, or three times), type (verbal, physical, sexual, or other), anticipated stressors, and reporting of violence experienced.
An online, self-administered and structured questionnaire was used for data collection with the survey questions adapted from previous studies on WPV [14,26]. The questionnaire consisted of two parts; the first part explored the sociodemographic and work-related characteristics of respondents and whether they experienced WPV during the COVID-19 pandemic or not. The second part comprised further questions to those polled, it was about violence patterns experienced (frequency, type, reasons, and reporting of attacks). The link to the final questionnaire was distributed to participants using Google forms through electronic mail addresses and virtual groups on social media platforms, including Facebook, WhatsApp, Twitter, and Telegram. Data were collected from August to December 2021. To account for sample selection bias, we distributed the electronic survey using verified electronic mail addresses of HCWs in Sudan. In addition, the sample size was increased by 100% to account for future need for stratification. Moreover, it was not permitted to submit more than one survey.

Data analysis
Data analysis was done using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). The Kolmogorov-Smirnov was used to verify the normality of the distribution of variables. Descriptive statistics were produced. The bivariate analysis was conducted to examine factors associated with suffering WPV. The significance of the obtained results was determined at a p < 0.05.

Ethical considerations
This study has been approved by the Health Sector Ethical Review Committee, Faculty of Medicine, University of Gezira, Sudan. An information sheet outlining the research purpose was sent before the questionnaire, followed by an invitation to participate and informed consent.

RESULTS
A total of 792 HCWs responded and returned the online questionnaire. The sample size more than doubled based on the enthusiastic response to the survey. These respondents are part of the human resources of Sudan embedded in a health system based on the district health system approach, with an estimated number of 1.2 hospitals and 13.5 primary health clinics serving 100,000 residents. According to the 2019 statistical report of the Federal Ministry of Health in Sudan, the total number of registered medical and other health workers is 49,354, with 5.6 physicians and 47.6 nurses and midwives per 10,000 population.
The respondents have a mean age of 33.5 ± 8.6 years. Over half of the respondents were females (54.9%) and working during the day shift (58.8%). Many of the participants were physicians (43.9%), single (49.2%), and with < 5 years of experience (48.2%) ( Table 1).
The magnitude of WPV is shown in Figure 1. Three in every four participants (78.3%) reported experiencing violence during the COVID-19 pandemic. The frequency and pattern of violence against HCWs are presented in Table 2. Nearly two-thirds (65.8%) reported experiencing violence more than three times. The most common type was verbal (swearing or screaming) violence, reported by 91.6 % of those polled, while half of the respondents suffered physical violence (50%). The emergency department was the primary location of 46.9 % of the violent incidents. In most incidents (87.9%), patients' families were the offenders, and the most perceived triggers for violence were lack of staff, drugs, or medical equipment in the hospital (28.9%), followed by unexpected patient death or complications (19.7%). Half of the events (50.3%) were not reported primarily due to the lack of a reporting system in the hospital or health center. Results of the unadjusted analysis of factors associated with suffering WPV during the COVID-19 pandemic are presented in Table 3. The demographic factors that were significantly associated with exposure to violence were participants' occupation (p < 0.001), age (p = 0.001), marital status (p = 0.002), and years of working experience (p = 0.020). However, there was no significant association between exposure to violence and HCWs' sex (p = 0.548) or shift time worked (p = 0.059).

DISCUSSION
High proportions of HCWs in Sudan had experienced WPV during the COVID-19 pandemic. The current study findings point to the catastrophic and complicated case of WPV against HCWs in Sudan, which calls for immediate and radical interventions. A previous study of WPV among physicians in Khartoum state in Sudan reported a 50% magnitude of WPV during 2019-2020 [14]. Accordingly, the current findings suggest that the COVID-19 pandemic has aggravated the frequency of WPV in Sudan. This result can be compared with a study in Iraq in which 87.3% of physicians experienced hospital violence [20]. Also, studies from Jordan, Brazil, and China reported that 65.5%, 47.6%, and 20.4% of HCWs were exposed to WPV, respectively [5,27,28]. Verbal abuse was the most common (91.6%) type of violence encountered by the current study respondents. This was the case in China, as 94.1% of frontline clinicians suffered verbal abuse during the pandemic [29]. Overall, these findings prompt the need for contextually applicable measures, as implementing a uniform solution that suits all is unlikely to be effective. The emergency department had the largest percentage of violent events (46.9%). This finding is consistent with previous studies of WPV in Sudan [14]. This could be explained by heightened emotional tension because of the situation of the patients, and thus, the relatives and patients are more emotionally volatile. In addition to the emotionally charged, overworked and stressed workers in emergency settings [16,30]. Moreover, this result could also be related to political protests in Sudan during the epidemic, where hospitals' emergency departments and HCWs were frequently attacked by security forces [31]. Similarly to this result, the likelihood of violence was higher among emergency department workers in both China and Ethiopia [29,32]. The current study found that patients' families were the most violent offenders. The same was noted in studies from Egypt, Palestine, and India [21,33,34]. The lack of staff, drugs, or medical equipment in the hospital was the most common perceived trigger for violence in the current study. Similarly, multiple shortcomings of the health services were the triggers of violence against physicians treating COVID-19 patients in Peru [35]. This result is significant because knowing the reason and implementing a comprehensive health and safety preventive strategy are the keys to understanding, preventing, and dealing with WPV. The multiple gaps and deficiencies seen in hospitals during the pandemic should be a lesson to create a necessary protocol and increase workplace safety in favor of medical personnel for the future. Our findings showed that half of the attacks were not reported primarily due to the lack of reporting systems. Underreporting of violent attacks is widely documented in the published literature on WPV. This issue exists for many reasons; many HCWs consider violence a part of the job, and some believe that no action will be taken against perpetrators, in addition to the lack of awareness about policies and reporting systems [36]. In a study among Chinese nurses, half of the participants were unaware of how and what types of violence to report, and half believed that the hospital paid greater attention to patients rather than the staff [37]. Another study showed that only less than a third of HCWs who experienced verbal and physical violence had reported the incidents to the hospital authority, with more than half believing that no action was taken against the offenders [6]. This was also true among nurses in Ethiopia, where more than half confirmed the lack of reporting procedures [32].
According to the current study findings, age, marital status, years of work experience, and occupation were strongly associated with exposure to violence. When dealing with WPV, these factors play a significant role in influencing subsequent responses. For example, older HCWs with more experience would expect to have better communication skills and more training and practice of de-escalation strategies that emphasize improvements in behavioral responses in the case of an assault. A study of Chinese frontline HCWs during the COVID-19 epidemic found that WPV was significantly associated with participants' sociodemographic factors [29]. In the current study, however, there was no significant relationship between exposure to violence and HCWs' gender or time shift worked. This finding magnifies the extent of the problem, both genders might suffer WPV at any time, which could be due to the increased frequency of violence each day in Sudan amid political protests and conflict. Similarly, there was no difference in reports of violence between male and female doctors during the pandemic in Iraq [20]. Though, there are mixed findings on the relationship of sex/gender with WPV during the COVID-19 pandemic. For example, a study conducted among Peruvian HCWs has demonstrated that the female gender was significantly associated with increased odds of suffering violence and aggression [35]. In contrast, the male gender was a significant predictor of suffering WPV during the COVID-19 pandemic among Jordanian and Chinese HCWs [5,29].

Limitations
This study encountered several limitations; despite efforts to adjust for sampling bias, the use of the non-probability convenience sampling in recruiting participants limits the study findings' generalizability to all HCWs in Sudan. In addition, using an onlinebased questionnaire for data collection poses a risk of selection bias favoring only HCWs with active access to the internet. Since the present study further assessed previous experience with violent events, the results are prone to recall bias. Finally, we used a self-report questionnaire for data collection, hence our findings might have been affected by social desirability bias.

CONCLUSIONS
WPV was rampant among the HCWs in Sudan during the COVID-19 pandemic. The most agreed upon triggers of WPV in the present study were lack of staff, drugs, or medical equipment in the hospital, and unexpected patient death or complications. Participants' age, marital status, years of working experience, and occupation were significantly associated with suffering WPV. The current findings are presented to draw the attention of policy leaders and stakeholders to this alarming problem in Sudan and prompt the need for policy and system interventions.

C O N F L I C T O F I N T E R E S T Elhadi Y.
A.M is a Youth Editorial Board member of Public Health Challenges and co-author of this article. He was excluded from editorial decision-making related to the acceptance of this article for publication in the journal.

D ATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E T H I C A L A P P R O VA L S TAT E M E N T
This study has been approved by the Health Sector Ethical Review Committee, Faculty of Medicine, University of Gezira in Sudan.